Citation Nr: 21072937 Decision Date: 12/06/21 Archive Date: 12/06/21 DOCKET NO. 17-43 129 DATE: December 6, 2021 ORDER A disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is denied. A disability rating in excess of 30 percent for asthma, effective prior to July 2, 2014, is denied. A disability rating in excess of 30 percent for allergic rhinitis is denied. A disability rating in excess of 30 percent for sinusitis is denied. REMANDED Entitlement to service connection for a lumbar or thoracic spine disability is remanded. FINDINGS OF FACT 1. The Veteran's psychiatric disorder is manifested by occupational and social impairment with reduced reliability and productivity due to symptoms such as anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, and difficulty establishing and maintaining effective work and social relationships. 2. For the appeal period prior to July 2, 2014, and thereafter, the Veteran's asthma did not require at least three courses of systemic (oral or parenteral) corticosteroids per year, at least monthly visits to a physician for required care, or manifest in a forced expiratory volume in one second (FEV-1) of 40 to 55 percent predicted or worse, a forced expiratory volume in one second to forced vital capacity ratio (FEV-1/FVC) of 40 to 50 percent predicted or worse or more than one attack per week with episodes of respiratory failure. 3. From the date of service connection, the Veteran has been in receipt of the maximum schedular rating for his service-connected allergic rhinitis. 4. From the date of service connection, the Veteran's chronic sinusitis more nearly approximated sinus symptoms manifested by more than six non-incapacitating episodes per year characterized by headaches, pain, and purulent discharge; the Veteran's chronic sinusitis was not manifested by radical surgery with chronic osteomyelitis, or near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 50 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 2. The criteria for a disability rating in excess of 30 percent, effective prior to July 2, 2014, for asthma have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.96, 4.97, Diagnostic Code 6602. 3. The criteria for a disability rating in excess of 30 percent for allergic rhinitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.97, Diagnostic Code 6522. 4. The criteria for a disability rating in excess of 30 percent rating for sinusitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.97, Diagnostic Code 6510. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the U.S. Air Force Reserve and Air National Guard from June 1981 to April 1991. He had active duty in August and December 1990, and periods of active-duty training (ACDUTRA) and inactive duty training (IDT). This appeal proceeds from rating decisions from the Department of Veterans Affairs (VA) Regional Office (RO) issued in March 2014, July 2015, April 2017, and July 2017. This matter was before the Board in January 2020, at which time the Board, in pertinent part, granted entitlement to service connection for obstructive sleep apnea, and remanded the issues of an increased rating for asthma with sinusitis and allergic rhinitis and PTSD, as well as service connection for a lumbar or thoracic spine disability. During the remand, in a February 2020 rating decision, the RO granted separate 30 percent ratings each for allergic rhinitis and sinusitis, effective December 26, 2012. As the Board noted in its January 2020 remand, the initial rating assigned for service connection for sinusitis and rhinitis, which was granted and combined with the already service-connected asthma, was part of the issue on appeal. As the Veteran has not indicated that he is satisfied with the separate 30 percent ratings for allergic rhinitis and sinusitis, which the Board previously took jurisdiction over as part of the claim for asthma, these matters are still before the Board. See AB v. Brown, 6 Vet. App. 35, 38 (1993). In an August 2020 rating decision, the RO effectuated the January 2020 Board decision granting entitlement to service connection for obstructive sleep apnea and reclassified the disability as "obstructive sleep apnea with asthma," and assigned a 50 percent rating, effective July 2, 2014. The RO recharacterized the Veteran's service-connected asthma (previously rated under Diagnostic Code 6602 as 30 percent disabling) and established a disability rating of 50 percent for obstructive sleep apnea with asthma under Diagnostic Codes 6602-6847, based on the severity of the sleep apnea. The Veteran did not disagree with the 50 percent rating assigned for obstructive sleep apnea with asthma. Therefore, the Board will only address the impairment associated with the asthma prior to July 2, 2014, as well as whether the Veteran's asthma alone would warrant a rating higher than 50 percent, thereafter. The Board finds that the directives of its January 2020 remand have been substantially complied with, as pertaining to the increased rating claim for PTSD, allergic rhinitis, sinusitis, and asthma, the case is now returned for appellate review. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (Board remand confers a right on a claimant to compliance with the remand order); Dyment v. West, 13 Vet. App. 141, 147 (1999) (clarifying that substantial compliance with Board remand is required). As discussed in the remand section below, additional development is still warranted for the service connection claim for a lumbar or thoracic spine disability. Finally, the Board notes that the Veteran's attorney filed a letter in April 2021 indicating that as of the date of the letter, the attorney was "no longer representing" the Veteran. Generally, "after an appeal to the Board of Veterans' Appeals has been filed, a representative may not withdraw services as representative in the appeal unless good cause is shown on motion." 38 C.F.R. § 20.6 (a)(2). Good cause for such purposes is the extended illness or incapacitation of the representative; failure of the appellant to cooperate with proper preparation and presentation of the appeal; or other factors which make the continuation of representation impossible, impractical, or unethical. 38 C.F.R. § 20.608 (b)(2). However, and not for the first time, the Veteran's attorney has failed to properly withdraw his representation of a client in accordance with 38 C.F.R. §§ 20.6 (b); 14.631. As the claims on appeal have been certified to the Board, and good cause has not been shown for the withdrawal, the Board finds that Attorney Woods remains the Veteran's properly appointed representative in these matters. See 38 C.F.R. §§ 14.631, 20.608, 20.6; see also Williams v. Wilkie, 32 Vet. App. 46 (2019). The Board notes that, as the remaining issue involved in this appeal is being remanded, the Veteran's attorney is welcome to follow the procedures outlined in 38 C.F.R. § 14.631 (c) and properly withdraw his representation on remand. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4. The Board determines the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.10. Where there is a question as to which of two ratings should be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, staged ratings are also appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, analysis in this decision has therefore been undertaken with consideration of the possibility that different ratings may be warranted for different time periods as to the pending claims. 1. Entitlement to an increased rating higher than 50 percent for PTSD The Veteran seeks a disability rating higher than 50 percent for his service-connected PTSD. The Veteran's PTSD is rated under the General Formula for Mental Disorders (General Formula), Diagnostic Code 9411. Under that code, a 50 percent rating is assigned when symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name. The Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). A July 2013 VA examination report shows the Veteran reported nightmares, difficulty staying asleep, and feeling irritable and frequently physically agitated. He had anxiety attacks involving feeling an increased heart rate and feeling tense. He felt that he had to check and lock windows in the middle of the night when he would wake. He also related having low energy and motivation. He tended to avoid people and stated that he did not trust anyone. He was socially isolated and did not socialize except for his family. He tended to avoid discussions and conversations about his service. Overall, the examiner found that he had occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. Socially, the Veteran was married to his second wife for the past 12 years. He reported having a good relationship with his wife and children. He stated that he had three good friends but that he mostly spent time with his wife and children. He related having a good relationship with his mother but had not spoken to his father for 10 years. He described his father as alcoholic and emotionally abusive growing up. He had a good relationship with his brother and sister but did not talk much to his other brother. Occupationally, the Veteran had worked as a commercial pilot after separation from service. He was presently working as a forensic architect. The Veteran initiated psychiatric treatment in January 2013. He denied any history of or current suicidal ideation, homicidal ideation, self-harming behaviors, or audio-visual hallucination. He noted that a few years ago he was arrested in an incident while driving where a limousine cut him off in traffic and almost caused him to be in a head-on accident. He described becoming enraged and taking a hammer and hitting the limousine multiple times with the hammer. He was arrested but the charges were dropped. He denied any other history of being arrested. The examiner noted that the symptoms associated with the Veteran's PTSD diagnosis included anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, and difficulty establishing and maintaining effective work and social relationships. The Veteran's wife submitted a statement in July 2013 that she had been married to the Veteran for the past 12 years and had witnessed his reaction to recurring nightmares related to his military service. She noted that he would wake up in the morning exhausted to begin his workday, which would affect his ability to concentrate at work. This also had a negative effect on his personality. He resorted to bringing an inflatable mattress at the office for naps to get him through the day. She noted that he was a self-employed architect and the sole provider of their family. An April 2017 VA mental health note shows the Veteran continued to have some difficulty at night with tossing/ turning, snoring, and yelling out. He reported that his mood was even and rated his level of sadness and irritability at a 3 out of 10. He reported some anxiety, but it appeared to be manageable. He denied suicidal and homicidal ideations and audiovisual hallucinations. He continued to work 8 plus hours a day and reported some stress associated with it. An October 2017 VA treatment record notes the Veteran had a diagnosis of generalized anxiety disorder, insomnia associated with obstructive sleep apnea, and chronic PTSD. It was noted that the Veteran had last been seen in April 2017. He reported poor sleep averaging three to four hours with trouble maintaining sleep. He reported having nightmares around two times a week when he would wake up with sweats. He also admitted to not using his CPAP machine regularly. He stated that exercise was a "stress reliever" for him and that his work kept him preoccupied. He denied any anxiety during the day. An October 2019 VA mental health note shows that the Veteran reported that his mood was "okay" and his appetite fine. He stated that he was a type A personality, busy at work as a forensic architect in private practice, and still flew his private small plane, continued to train physically, and denied mood or anxiety impairment. It was noted that he had a history of PTSD but had no active PTSD symptoms at that time. In February 2020, a VA mental health record shows that the Veteran reported that he could not sleep in the same bed as his spouse because of significant sleep movements and making loud snoring noises and other noises throughout the night. He reported that is mood was stable. He continued to work as a forensic architect and flew a private plane and he exercised regularly. He reported no passive death wishes, suicidal or homicidal ideations, and had no manic or psychotic symptoms. The Veteran underwent another VA examination in November 2020. The examiner found that the Veteran no longer met the full criteria for PTSD per DSM-5, despite some symptoms persisting and/ or increasing over the past year. The examiner found that the Veteran now met the criteria for adjustment disorder with anxiety. He noted that his disturbed sleep resulted in his wife no longer sleeping in the same bed as he did. She could not sleep due to his kicking, punching, turning, and awakening during the night. He did not indicate that he believed that this had placed any strain on the marriage. He also noted that he was less hesitant to go out but that he and his wife were "homebodies" and focused more on family. COVID also was a limiting factor. The Veteran noted more impact on his occupational functioning, stating that he needed to keep an air mattress at work due to fatigue resulting from his limited restless sleep. Further, he indicated that his line of work made very high demands on cognition, and he was noticing some issues in this area (mild distractability, occasionally forgetting some details, and needing to put more time in to solve problems that he would rapidly find solutions under more ideal circumstances). The Veteran also indicated that he had to do a not-insignificant amount of longer-distance driving as a part of his job and noted that he sometimes was fearful he would fall asleep during the drives due to fatigue. The examiner commented that reduced sleep could result in decreased cognitive performance. The examiner found that the Veteran had occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. Socially, since the prior VA examination, the Veteran stated that he had watched his children grow, noting one is in college, one in high school. He was still living with his wife and happily married. He stated that he and his wife were more stay-at-home folks, focusing more on spending time as a family. Occupationally, the Veteran had transitioned from forensic architect to more federal contracting, serving as a project manager for larger civil projects. He noted that he felt that his new line of work was more rewarding but also noted that the type of work he was doing started to dry up as the effects of the recession ended. He stated that he was enjoying the work. The examiner found that symptoms that applied to the Veteran's diagnosis of adjustment disorder with anxiety included anxiety and chronic sleep impairment. The Veteran endorsed mild levels of anxious symptoms, including feelings of tension and restlessness, impaired sleep, nervousness, and increased irritability. He endorsed minimal depressive symptoms, limited to mild anhedonia. Based on this evidence, the Board finds the level of impairment caused by the Veteran's symptoms more closely approximates the level associated with a 50 percent rating throughout the appeal. The Veteran experienced occupational and social impairment with reduced reliability and productivity. VA examination reports and VA treatment records noted that the Veteran had symptoms such as anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, and difficulty establishing and maintaining effective work and social relationships. Socially, the Veteran was married to his second wife for approximately 20 years and reported having a good relationship with his wife and children. He stated that he had three good friends but that he mostly spent time with his wife and children. He was somewhat socially isolated and did not socialize except for his family. He related having a good relationship with his mother but had not spoken to his father for 10 years and had a good relationship with his brother and sister but did not talk much to his other brother. He had nightmares that interfered with his ability to sleep in the same bed with his wife. He also had a history of irritability and feeling physically agitated. At night he would check and lock windows in the middle of the night when he would wake. He also related having low energy and motivation. Occupationally, the Veteran had worked as a commercial pilot after separation from service. He was presently working as a federal contractor, serving as a project manager for larger civil projects, having transitioned from being a forensic architect. He also flew a private plane. He noticed some issues with occasionally forgetting some details and needing to put more time in to solve problems that he would rapidly find solutions under more ideal circumstances. The Veteran did experience some symptoms contemplated by a 70 percent rating, such as obsessional rituals which interfere with routine activities, when it was noted that he would check the locks at night when he could not sleep. He also reportedly hit another car with a hammer after the car nearly caused him to be in a head-on collision while driving, demonstrating impaired impulse control, though this arguably was not unprovoked. Nonetheless, the evidence overall does not demonstrate the level of impairment associated with a 70 percent rating. As noted above, the Veteran's other remaining symptoms were either contemplated by or more consistent with a 50 percent rating. Further, while the Veteran complained of fatigue and some trouble with memory and focus, prior and subsequent treatment records contain reports that the Veteran was generally performing well at work. In fact, during the November 2020 VA examination, the Veteran reported that he felt that his new line of work was more rewarding and that he was enjoying the work. Overall, the Board finds that the bulk of the evidence, consisting of multiple mental health treatment records and VA mental health examinations spanning over 8 years, supports a finding that the Veteran's symptoms, as a whole, more closely approximate the criteria for his current disability rating of 50 percent. Thus, the Board finds that at no time during the rating period on appeal has the Veteran's PTSD warranted a rating in excess of 50 percent. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). The claim is denied. 2. Entitlement to an increased rating higher than 30 percent for asthma, effective prior to July 2, 2014 The Veteran asserts that his asthma is more severe than contemplated by the current rating assigned. The Veteran's asthma is evaluated under Diagnostic Code 6602, which contemplates bronchial asthma, in part using the results of pulmonary function tests (PFTs). 38 C.F.R. § 4.97. Under Diagnostic Code 6602, a 30 percent rating is warranted for FEV-1 of 56 to 70 percent predicted; or FEV-1/FVC of 56 to 70 percent; or daily inhalational or oral bronchodilator therapy or inhalational anti-inflammatory medication. A 60 percent rating is warranted for FEV 1 of 40 to 55 percent predicted; or FEV 1/FVC of 40 to 55 percent; or at least monthly visits to a physician for required care of exacerbations; or intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids. A maximum 100 percent disability rating is assigned for FEV 1 of less than 40 percent; or more than one attack per week with episodes of respiratory failure; or required daily use of systemic (oral or parenteral) high dose corticosteroids or immune suppressive medications. The Board notes that, when evaluating based on Pulmonary Function Testing (PFT), VA is to use post-bronchodilator results unless the post-bronchodilator results were poorer than pre-bronchodilator results, in which case the latter should be used instead. 38 C.F.R. § 4.96 (d)(5). When there is a disparity between the results of different PFTs (e.g., FEV-1, FVC, or FEV-1/FVC) such that the evaluation would be different depending on which test was used, the Board must use the test result that the examiner states most accurately reflects the level of disability. 38 C.F.R. § 4.96 (d)(6). The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other. Esteban v. Brown, 6 Vet. App. 259, 262 (1994); 38 C.F.R. § 4.14. As noted in the introduction, in an August 2020 rating decision that effectuated the Board's grant of service connection for sleep apnea in January 2020, effective July 2, 2014, the Veteran was assigned a 50 percent rating for sleep apnea with asthma under Diagnostic Code 6602-6847. The provisions of 38 C.F.R. § 4.96 (a) specifically prohibit the assignment of separate evaluations for asthma and obstructive sleep apnea. See 38 C.F.R. § 4.96. (Ratings under Diagnostic Codes 6600 through 6817 (of which asthma is 6602) and 6822 through 6847 (of which sleep apnea is 6847) cannot be combined with each other). The Board notes that the evidence of record supports a finding that the disabilities at issue present with duplicative and overlapping manifestations, namely difficulty with breathing. Section 4.14 clearly contemplates that several separately diagnosed disorders may have a single manifestation, and it clearly prohibits the VA from rating that manifestation for each disorder. See 38 C.F.R. § 4.14; Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009). Thus, the Board is bound by 38 C.F.R. § 4.96 (a), which specifically prohibits the assignment of separate evaluations for asthma and obstructive sleep apnea. Additionally, the Board notes that the Veteran did not appeal the August 2020 rating decision granting service connection for sleep apnea, recharacterized as service-connected obstructive sleep apnea with asthma. Thus, the claim is limited to entitlement to an initial rating higher than 30 percent for asthma, prior to July 2, 2014, and whether the asthma alone would warrant a rating higher than 50 percent, thereafter; and the Board will limit its review of the evidence accordingly. Turning to the evidence, a February 2013 private treatment record notes that the Veteran was under the physician's care for chronic bronchial asthma. He currently took Advair 500 along with Singulair. He also had recurrent endobronchial infections treated with high dose of Augmentin and a combination of Biaxin and Omnicef. The infection had occurred five to six times yearly for the last three years. A February 2013 respiratory condition Disability Benefits Questionnaire (DBQ) submitted by a private physician notes that the Veteran had a diagnosis of asthma since December 1991 and chronic obstructive pulmonary disease (COPD), as well as mildly emphysematous lungs, since February 2013. The symptoms related to the diagnoses were chronic fatigue, dizziness, sleep dysfunction, and physical activity restrictions. The Veteran's respiratory condition impacted his ability to work in that he was ill frequently and tried to minimize the impact that this had on his work as he was less productive when he was ill. The examiner found that the Veteran's respiratory condition required the use of oral or parenteral corticosteroid medications, including four or more intermittent courses. It also was noted that the respiratory condition required daily use of systemic (oral or parenteral) high does corticosteroids or immunosuppressive medications. In addition, it was noted that the Veteran used a daily high dose inhaled corticosteroid (Advair 500mg). The Veteran's respiratory condition also required daily inhalational bronchodilator therapy, daily inhalational anti-inflammatory medication, and inhaled medication of Symbicort for COPD. In addition, the Veteran's respiratory condition required the use of antibiotics. The Veteran had asthma and had not had any asthma attacks with respiratory failure in the past 12 months. He had had severe attacks in 2012, however, that required oral prednisone. The attacks were less frequently than monthly. The report noted that a pulmonary function test (PFT) had been performed in July 2012 and showed prebronchodilator readings of FVC of 94 percent predicted, FEV-1 of 102 percent predicted, and FEV-1/ FVC of 75 percent. The examiner noted that the test result that most accurately reflected the Veteran's level of disability was the reading of FEV-1. As noted above, when evaluating based on PFT, VA is to use post-bronchodilator results unless the post-bronchodilator results were poorer than pre-bronchodilator results, in which case the latter should be used instead. 38 C.F.R. § 4.96 (d)(5). The examiner noted that post-bronchodilator resting had not been completed because the pre-bronchodilator results were normal. The examiner noted that the condition which was primarily responsible for the limitation in pulmonary function was asthma. His respiratory medications included Symbicort for COPD, Proventil HFA (Albuterol Sulfate), Asmanex Twisthaler (mometasone furoate), Montelukast NA, Cetirizine, and Clarithromycin. A September 2014 VA examination report shows that the Veteran had a diagnosis of asthma. The Veteran also noted that he had become prone to lung infections and had to be on antibiotics six times. The Veteran's asthma required daily inhalational bronchodilator therapy and daily inhalational anti-inflammatory medication. The Veteran's respiratory condition did not require the use of oral bronchodilators, antibiotics, or require outpatient oxygen therapy. The Veteran had not had any asthma attacks with episodes of respiratory failure in the past 12 months. He also had not had any physician visits for required care of exacerbations. PFT studies in April 2013 showed post-bronchodilator readings of FVC 114 percent predicted, FEV-1 107 percent predicted, FEV-1/ FVC 72 percent. It was noted that the test result that most accurately reflected the Veteran's level of disability (based on the condition that was being evaluated for this report) was FEV-1/FVC. The impact on the Veteran's ability to work was that he complained of baseline shortness of breath. He was short of breath all the time, especially with exertion. This limited his physical activity. He stated that he was prone to lung infections if he did not use his inhalers. A May 2017 VA pulmonary clinic note shows the Veteran was seen in 2013 for asthma and had follow up in 2015 but had not been back since. The Veteran complained that his asthma symptoms were every day, and his asthma was uncontrolled as it came in the way of his day-to-day activity. He used Symbicort once a day, two puffs, and sometimes he used one puff in the evening. In addition he took albuterol, two puffs as needed. He usually needed about two to four puffs in a day. PFTs in March 2017 showed a very mild obstruction with an FEV-1 of 69 percent, which, the examiner noted after bronchodilator was normal. Lung volumes were normal and diffusing capacity was normal. The assessment for his asthma was that he had moderate to severe persistent asthma, which was uncontrolled. Part of the reason was his insufficient use of inhaled corticosteroids. A November 2020 VA examination report shows the Veteran reported that he had a history of asthma controlled with his medications and inhalers that started gradually over time. His respiratory condition did not require the use of oral or parenteral corticosteroid medications. His respiratory condition required daily inhalational bronchodilator therapy and daily inhalational anti-inflammatory medication. His respiratory condition also required the use of oral bronchodilators. His respiratory condition did not require the use of antibiotics or required oxygen therapy. The Veteran had not had any asthma attacks with episodes of respiratory failure in the past 12 months. He also had not required the care by a physician for exacerbations. A chest x-ray was provided, which was within normal limits. PFT results showed post-bronchodilator readings of FVC 98 percent predicted, FEV-1 102 percent predicted, and FEV-1/ FVC 105 percent. The test result that most accurately reflected the Veteran's level of disability was FEV-1/ FVC. It was noted that the Veteran did not have multiple respiratory conditions. Based on the foregoing, the Board finds that a rating in excess of 30 percent for asthma, prior to July 2, 2014, is not warranted. In this regard, the Veteran's asthma has not been shown to have FEV-1 of 40 to 55 percent predicted; or FEV-1/FVC of 40 to 55 percent. Rather, the February 2013 DBQ showed prebronchodilator readings of FVC of 94 percent predicted, FEV-1 of 102 percent predicted, and FEV-1/ FVC of 75 percent. The examiner noted that the test result that most accurately reflected the Veteran's level of disability was the reading of FEV-1. PFT studies in April 2013 showed post-bronchodilator readings of FVC 114 percent predicted, FEV-1 107 percent predicted, FEV-1/ FVC 72 percent. It was noted that the test result that most accurately reflected the Veteran's level of disability (based on the condition that was being evaluated for this report) was FEV-1/FVC. As for at least monthly visits to a physician for required care of exacerbations or intermittent course of systemic corticosteroids of at least three courses per year, which are two of the criteria for a 60 percent rating under Diagnostic Code 6602, the February 2013 DBQ noted that in addition to asthma the Veteran had COPD and mildly emphysematous lungs, and that the Veteran's respiratory condition required the use of oral or parenteral corticosteroid medications, including four or more intermittent courses. It also was noted that the respiratory condition required daily use of systemic (oral or parenteral) high dose corticosteroids or immunosuppressive medications. Under Diagnostic Code 6602, asthma that requires daily use of systemic (oral or parenteral) high dose corticosteroids or immunosuppressive medications would warrant a 100 percent disability rating. The February 2013 DBQ finding pertaining to the use of systemic high dose steroids for asthma is inconsistent with the rest of the findings on the report, as it pertains to the Veteran's asthma, as it is noted that his asthma results in normal PFT results, pre-bronchodilator. Also, while the report noted that his asthma attacks specifically were severe enough in 2012 to require oral prednisone, the attacks were less frequent than monthly. Thus, the findings pertaining to the daily use of systemic high dose corticosteroids are not shown as being applicable to the Veteran's asthma, and the probative value of that finding is undermined by the inconsistencies of the rest of the medical evidence. The report itself also notes that the Veteran's asthma attacks required oral prednisone treatment less than monthly. Prior to July 2, 2014, the Veteran was not shown, nor has he alleged, that he required the use of intermittent corticosteroid medication of at least three courses in the past twelve months; nor has the evidence shown the Veteran had FEV-1 of 40 to 55 percent predicted; or FEV 1/FVC of 40 to 55 percent; or at least monthly visits to a physician for required care of exacerbations. Accordingly, the Board finds that the Veteran's asthma does not warrant an initial rating in excess of 30 percent prior to July 2, 2014. Moreover, beginning July 2, 2014, a rating higher than the 50 percent rating for sleep apnea with asthma is not warranted, as the Veteran was not shown, nor has he alleged, that he required the use of intermittent corticosteroid medication of at least three courses in the past twelve months; nor has the evidence shown the Veteran had FEV-1 of 40 to 55 percent predicted; or FEV 1/FVC of 40 to 55 percent; or at least monthly visits to a physician for required care of exacerbations. A September 2014 VA examination report shows that the Veteran's asthma required daily inhalational bronchodilator therapy and daily inhalational anti-inflammatory medication. He had not had any asthma attacks with episodes of respiratory failure in the past 12 months. He also had not had any physician visits for required care of exacerbations. PFTs in March 2017 showed a very mild obstruction with an FEV-1 of 69 percent, which was noted after bronchodilator, as normal. Lung volumes were normal and diffusing capacity was normal. The assessment for his asthma is that he had moderate to severe persistent asthma, which is uncontrolled. Part of the reason was his insufficient use of inhaled corticosteroids. The Veteran's asthma in November 2020 also was noted as requiring daily inhalational bronchodilator therapy and daily inhalational anti-inflammatory medication. His respiratory condition also required the use of oral bronchodilators. He had not had any asthma attacks with episodes of respiratory failure in the past 12 months. He also had not required the care by a physician for exacerbations. PFT results showed post-bronchodilator readings of FVC 98 percent predicted, FEV-1 102 percent predicted, and FEV-1/ FVC 105 percent. The test result that most accurately reflected the Veteran's level of disability was FEV-1/ FVC. It was noted that the Veteran did not have multiple respiratory conditions. Accordingly, the Board finds that the Veteran's asthma does not warrant a rating higher than the 50 percent rating assigned for sleep apnea and asthma, effective July 2, 2014. In addition, as noted, as both asthma and obstructive sleep apnea are both necessarily manifested by lung or pleural involvement, separate ratings are prohibited by 38 C.F.R. § 4.96 (a). In making its determination, the Board acknowledges the Veteran's belief that his asthma symptoms are more severe than the current rating reflects. While the Board recognizes that the Veteran is competent to provide statements regarding his observable symptomatology, he is not competent to provide an opinion regarding the severity of his symptomatology in accordance with the rating criteria. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Rather, the Board finds the medical evidence in which professionals with medical expertise examined the Veteran, acknowledged his reported symptoms, and described the manifestations of such disability considering the rating criteria to be more persuasive than the Veteran's reports regarding the severity of his condition. Therefore, while the Board acknowledges the Veteran's reported asthma symptomology, the Board also finds that the Veteran is compensated for these problems in his current rating. The Board notes the contentions of the Veteran that his asthma is more severe than currently shown on examination; and the Board observes that the Veteran, while competent to report his observable symptoms, he is not competent to report that his asthma symptoms are of sufficient severity to warrant a higher rating under VA's tables for rating such disabilities because such an opinion requires medical expertise which he has not been shown to have. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Charles v. Principi, 16 Vet. App. 370 (2002). Even after considering such contentions as to the effects of the disability on his daily life, the Board finds that the criteria for a higher rating are not met. The Rating Schedule contemplates such impairment under the ordinary conditions of daily life. 38 C.F.R. § 4.10; see also Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007). For these reasons, the Board finds that a preponderance of the evidence is against the Veteran's claim for an initial increased rating in excess of 30 percent prior to July 2, 2014; and a rating higher than 50 percent for sleep apnea with asthma, effective, thereafter. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The claim is denied. 3. Entitlement to an increased rating higher than 30 percent for allergic rhinitis Under 38 C.F.R. § 4.97, Diagnostic Code 6522, the maximum schedular rating available for allergic rhinitis is 30 percent. Diagnostic Code 6522 pertains to allergic or vasomotor rhinitis. A 10 percent rating is warranted if such is without polyps, but with greater than 50 percent obstruction of nasal passage on both sides or complete obstruction on one side. A maximum 30 percent rating is warranted for rhinitis with polyps. Where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. In a January 2017 VA examination the Veteran was noted to have allergic rhinitis with polyps that block more than 50% of each nasal passage. A previous examination in February 2015 did not demonstrate this type of impairment but based on the nature of rhinitis being subject to flares, the Veteran was assigned the maximum rating of 30 percent for the entire appeals period from December 26, 2012. The Veteran is in receipt of the maximum possible schedular rating for allergic rhinitis for the entire period on appeal. Accordingly, a higher rating is not warranted. The Board has also considered the applicability of alternative diagnostic codes for rating this service-connected disability. However, because allergic rhinitis has its own code, Diagnostic Code 6522, rating by analogy under other codes is not permissible. Thus, higher ratings under another code provision are not appropriate. Copeland v. McDonald, 27 Vet. App. 333, 338 (2014). Further, the Veteran is also separately service-connected for sinusitis and using that diagnostic code to evaluate his service-connected allergic rhinitis with nasal polyps would violate the rules against pyramiding. Entitlement to a higher rating for sinusitis is addressed below. As noted above, the maximum rating available for chronic allergic rhinitis under Diagnostic Code 6522 is 30 percent. As the Veteran has been rated at the maximum rating of 30 percent for chronic allergic rhinitis from the date of service connection, there is no legal basis upon which to award a higher schedular rating. 38 C.F.R. § 4.97, Diagnostic Code 6522; Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). The claim is denied. 4. Entitlement to an increased rating higher than 30 percent for sinusitis As indicated above, the Veteran was granted a separate rating for sinusitis in a February 2020 rating decision, which assigned a 30 percent rating from December 26, 2012. For the reasons set forth below, the Board finds that a rating higher than 30 percent rating is not warranted for the Veteran's sinusitis from the date of service connection. The separately rated chronic sinusitis is evaluated under Diagnostic Code 6510 (pansinusitis, chronic). Under Diagnostic Code 6510, a noncompensable disability evaluation is warranted when sinusitis is detected by x-ray only. A 10 percent disability evaluation is warranted for one or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 30 percent evaluation is warranted for three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. The next and highest schedular rating of 50 percent is assigned following radical surgery with chronic osteomyelitis, or; near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. In the note section following the criteria, an incapacitating episode was defined as one requiring bed rest and treatment by a physician. 38 C.F.R. § 4.97, Diagnostic Code 6513. A January 2017 VA examination report shows that the Veteran had more than six non-incapacitating episodes of sinusitis per year. There were no incapacitating episodes of sinusitis noted. The previous examination in February 2015 did not show this type of impairment but since sinusitis is subject to flares, a 30 percent rating was assigned for the entire appeal, i.e., since December 26, 2012. A September 2017 VA primary care note shows the Veteran had chronic sinusitis with the last attack in May 2017. He was doing well until about four weeks ago when he got sinus pain, congestion, fatigue, and purulent rhinorrhea. There was no headache, but the sinus pain was worse in the right paranasal region and left paranasal area. The CT scan showed mild chronic sinusitis without significant interval change. It was noted that this was third attack of the year. A January 2021 VA treatment record notes the Veteran complained of upper respiratory infection symptoms with facial pressure, postnasal drip, and fatigue. He was treated for presumed acute sinusitis with Augmentin and Prednisone (though he said he never took the Prednisone) and started to feel better. However, he quickly relapsed after this was finished. He reported postnasal drip and fatigue and was concerned for ongoing sinus injection. He denied current facial pain/ pressure, current nasal obstruction, and current hyposmia. It also was noted that before the last three weeks he had been very happy with his nasal and sinus control. From the date of service connection, the Veteran's chronic sinusitis more nearly approximated sinus symptoms manifested by more than six non-incapacitating episodes per year characterized by headaches, pain, and purulent discharge. A disability rating in excess of 30 percent for sinusitis is not warranted at any time from the date of service connection. As noted above, a 50 percent evaluation is warranted following radical surgery with chronic osteomyelitis, or; near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. The Veteran has not undergone radical surgery or exhibited chronic osteomyelitis, an infection of the bone according to Dorland's Illustrated Medical Dictionary 1368 (31st Ed. 2007). The evidence does not otherwise show that the Veteran's sinusitis has been productive of constant or near constant sinusitis characterized by headaches, pain and tenderness of the affected sinus, and purulent discharge or crusting after repeated surgeries. As such, a 50 percent rating is not warranted at any time from the date of service connection. In sum, the Board has considered the entire record, including the Veteran's reported symptomatology and the objective clinical evidence. For the reasons set forth above, the Board finds that a rating higher than 30 percent is not warranted for a chronic sinusitis from October 21, 2008. 38 U.S.C. § 5107 (b); see also Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). The claim is denied. REASONS FOR REMAND 1. Entitlement to service connection for a lumbar or thoracic spine disability is remanded. In January 2020, the Board remanded the Veteran's lumbar or thoracic spine disability claim, finding that a February 2017 VA examination report did not consider the Veteran's competent reports concerning his injures and trauma during service through his duties as a pilot and ongoing complaints for which he did not seek treatment. After the remand a May 2021 medical opinion was obtained. In that opinion, it was determined that the Veteran's lumbar spine disability was not related to service because there was no evidence provided in the service treatment records documenting any type of injury. The opinion did not consider the Veteran's competent lay statements regarding his injuries in service and continued symptoms since service, and relied improperly on a lack of documentation of injury. Thus, the opinion is inadequate. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (holding that an examination was inadequate where the examiner did not comment on the veteran's report of in-service injury but relied on the service medical records to provide a negative opinion). Additionally, the issue of service connection for a lumbar spine as secondary to the service-connected PTSD also was raised by the record in a February 2013 private chiropractor statement that the Veteran had occasional flare-ups during high stress or increased physical demands. Upon remand, this theory of entitlement to service connection should be addressed, as well. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician to determine the nature and etiology of the Veteran's current back (lumbosacral or thoracic spine) disabilities. The examiner should determine whether the current back disabilities were at least as likely as not (that is, a 50 percent probability or greater) incurred as a result of the Veteran's active service duties as a pilot. The examiner must consider and discuss the Veteran's competent lay reports concerning his injuries or trauma during service through his duties as a pilot and his ongoing complaints for which he did not seek treatment, and which are generally consistent with his service records, as well his reports of private treatment since 1986, in addition to information in the available medical records during and after service. See VBMS statements dated December 26, 2012 (VA 21-4138) and May 13, 2014 (VA 21-4138); January 2013 Gulf War Registry examination (in January 9, 2017 CAPRI, starting on page 555). The examiner also should state whether the Veteran's back disabilities are at least as likely as not aggravated beyond their natural progression by service-connected disability PTSD, including during periods of stress. A detailed rationale for any opinion offered should be provided. JEREMY J. OLSEN Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Sarah B. Richmond, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.